Endoscopic submucosal dissection for duodenal tumors

Abstract

Recently, endoscopic submucosal dissection (ESD) for the duodenal tumors has come to be treated in many institutions, but has also showed many problems of feasibility and safety compared with endoscopic mucosal resection (EMR). Although duodenal ESD is expected to be more effective for the prevention of postoperative local recurrence, high incidence rate of duodenal perforation and emergency surgical rescue are big problem. Prophylactic mucosal closure by clipping device, polyglycolic acid sheets shielding, and the laparoscopic and endoscopic cooperative surgery are reported to be effective measures to overwhelm the various problems associated with duodenal ESD. However, duodenal ESD still has quite a bit of room for improvement of the procedure, and currently the indication should be well discussed before treatment in consideration of the expected therapeutic effect and complications.

Keywords: Duodenal tumor; endoscopic mucosal resection (EMR); endoscopic submucosal dissection (ESD).

Figure 1

A case of early duodenal cancer located at the descending part of the duodenum (A). Perforation was complicated on submucosal dissection as a small hole of the proper muscle layer, and the endoscopic suture was attempted by using clipping device (B). However, the perforated site was gradually torn to become a large hole during the endoscopic procedure and a failed clip was dropped into the retroperitoneum (C). After removing a failed clip, the perforation was completely closed, but ESD had become difficult to continue, resulting in the piecemeal resection by snaring (D). Administration of the carbapenem antibiotic was started during the procedure, and the patient was treated conservatively to be discharged a week after ESD.

Figure 2

The whole layer-resected specimen by duodenal EMR complicating a perforation (A). This histopathologic picture shows abundant Brunner’s gland at submucosal layer and a very thin proper muscle layer as 300–500 µm (B). This histopathologic picture makes it easy to understand the reason for high incidence rate of perforation associated with duodenal ESD.

Figure 3

A case of early duodenal cancer located at the superior duodenal angle (A). The lesion was resected by ESD, and the postoperative mucosal defect reached half of the circumference (B). To prevent a delayed perforation, the resected bed was sutured from the end of it by using a clipping device (C). The resected bed has been completely sutured (D).